AUTHORIZATION FOR CRIMINAL RECORD SEARCH
First Baptist Church | 414 North Main Street | Cleburne, TX 76033 (817) 645-6684 – church office | (817) 645-2685 – fax |
[email protected] AUTHORIZATION: By signing below, you authorize First Baptist Church of Cleburne, TX (FBCC) to request information about you from any public or private information source. The information FBCC receives may include information about your address history, social security number validity, criminal record, driving record, and any other information with public or private information sources. By signing below, you hereby release such information upon request, whether favorable or unfavorable, to any representative of FBCC. You acknowledge that a fax, image, or copy of this authorization is as valid as the original. You make this authorization to be valid for as long as you are a volunteer with FBCC. PERSONAL INFORMATION: Please print the information requested below to identify yourself for FBCC. FULL LEGAL NAME: _____________________________________________________________________________________ First Middle (o none) Last OTHER NAMES USED (including maiden name): ______________________________________________________________ CURRENT AND FORMER ADDRESSES: CURRENT _________________________________________ __________________________________ _________ _________ from Mo/Yr to Mo/Yr Street City, State, & Zip _________ _________ _________________________________________ __________________________________ from Mo/Yr to Mo/Yr Street City, State, & Zip _________ _________ _________________________________________ __________________________________ from Mo/Yr to Mo/Yr Street City, State, & Zip Some government agencies and other information sources require the following information when checking for records. FBCC will not use it for any other purposes. ______________________________________________ ___________________________________________________ DATE OF BIRTH SOCIAL SECURITY NUMBER ______________________________________________ ___________________________________________________ DRIVERS LICENSE NUMBER AND STATE NAME AS IT APPEARS ON DRIVERS LICENSE ______________________________________________ EMAIL ADDRESS I hereby release any individual from any and all liability for damages, of whatever kind or nature, which may at any time result to me on account of compliance, or any attempts to comply with this authorization. ____________________________________ ____________________________________ _________________________ PRINTED NAME SIGNATURE DATE SIGNED
FOR OFFICE USE ONLY
o CLEARED TO WORK WITH MINORS AT FBCC
o NOT CLEARED TO WORK WITH MINORS AT FBCC COMMENTS: __________________________________________________________________________________________ ______________________________________________________________________ ____________________________ SIGNATURE OF REPRESENTATIVE CONDUCTING BACKGROUND CHECK DATE /Volumes/Shares/Public/Background Checks/Authorization for Criminal Records Search Dec 2016.docx
REVISED 12/8/2016
